GW1-2023-02557_Well Construction - GW1_20230410

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATERZONEs
FROM TO DESCRIPTION
Well Contractor Name
125 It- 400 ft* 1rz GPM
4449-A 400 it. 565 ft. 1112 GFMI
NC Well Contractor Certification Number 15.OUTER:CASING for midti�cased`.wells;ORLIA'EP ifa Gcabl'e
Rowan Well Drilling FROM I TO DIAMETER THICKNESS MATERIAL
0 ft- 125 ft- 61/4 1 i°• SDR21 PVC
Company Name 16:INNER GASIiVG'OR TUBING eot ie>dial closed-lod
2.Well Construction Permit#:WELL 11 .2021 161393 FROM TO DLUMETER L THICKNESS I MATERWL "
List all applicable well construction permits(i.e.WC,County.State,Variance,etc.) f• ft. in.
3.Well Use(check well use): ft. ft. in•
Water Supply 1 Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS-1 MATERIAL
Agricultural []MunicipdTublic ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. ;n•
IndustriaUCommercial DResidential Water Supply(shared) a&:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Holeplug Gravity 13 bass
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SANDIGRAVEL-PACK ifa "licabTe
Aquifer Storage and Recovery Salinity Barrier FROM T iAI o NIATER EMPLACEMENTAIETHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [3SubsidenceControl ft. ft.
Geothermal Closed Loop)
Tracer 20`DRILLING LOG atta" additional sheets if necessa'"
( FROM TO DESCRIPTION color,hardness sotl/raek a rnio sae,etc.
Geothermal(Heating/Coolin Return Other(ex lain under#21 Remarks) 0 ft. t5 ft. clay
4.Date Well(s)Completed:3/7/23 Weu ID#112021161393 15 ft. 85 ft. Sandy overburden
5a.Well Location: as ft. 115 ft. Weathered Rode
Cornerstone III Properties 115 ft, 125 ft- Solid Rock
Facility/Owner Name Facility IDff(if applicable) % ft' - T=t. r
8149 Long Island rd, Catawba 28609 ft. "``�' R�° �`' i'R`� -•
ft. ARP 4. -9-2923
Physical Address,City,and Zip ft.
Catawba 470002876343 21:REMARKS
County Parcel Identification No.(PIN) irt5 , •-�-.r„ ,i r 1 r
'i:y G..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 40 39.830 N 80 5913.812 W 3 11
tgnature o Certified Well Contractor Date
6.is(are)the well(s)�x Permanent or Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or E)No with 15ANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of tile copy of this record has been provided to the well owner.
repair under 421 remarks section or am the back ofAisform. 23.Site diagram or additional well details.,
8.For Geoprobe/DPT or Closed-Loop Geothermal.Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary construction
also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection.Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 A1ail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test.• weir 24c.For Water Summiv&Iniection Wells: In addition to sending the fool to
the address(es) above, also submit one copy of this form within 30 days of
chlorine Amount: 1t6lbs completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Fort GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016.